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In the presented clinical case, we consider the surgical treatment of a 9-year-old girl with an extensive post-traumatic scalp wound in the parieto-occipital region resulting from hair getting into the moving mechanism of a go-kart car and incomplete separation of the scalp in the parieto-occipital region of the head. The early postoperative period (surgical treatment with primary wound closure) was complicated by the development of skin necrosis. An extensive wound defect in the soft tissues of the scalp (up to 150 cm2) was replaced with local related tissues. For this, various methods of plastic surgery were used in different areas of the wound defect: plastic surgery with local tissues, replacement of the defect with a rotated fascio-cutaneous flap and plastic surgery with local tissues using the dosed stretching method. The combined use of these methods made it possible to completely restore full-fledged soft tissues and hair of the injured parieto-occipital region.

Total separation of the scalp is a serious trauma in clinical practice. Common in adult women and rare in children. Among children, the most common cause of such injuries is animal bites, including dog bites. The article presents the experience of treating a two-year-old child who was admitted to the Regional Clinical Hospital No. 2 in Tyumen (Russia) with an extensive scalped wound of the scalp in combination with craniocerebral trauma, traumatic shock, multiple bitten wounds of the soft tissues of the head with a violation of the integrity of the upper lacrimal tubule. Immediately from the moment the child was transported by the ambulance team, anti-shock, antibacterial, decongestant, symptomatic therapy was started, primary surgical treatment of wounds was performed with restoration of the integrity of the upper lacrimal canal of the right eye. The child had no indications for neurosurgical intervention. The standard treatment for a detached scalp is, if possible, microsurgical replantation, but due to the impossibility of performing microsurgical replantation in this case (an infected wound, a skin flap was recognized as unviable by an interdisciplinary council), the defect was closed on a delayed basis with a fullthickness skin graft taking into account the blood supply and anatomical features bed. In this case, during the period of scalp plasty, there were no postoperative complications, the engraftment of autodermal grafts was satisfactory, and the healing of donor wounds was also satisfactory. The child was discharged for the outpatient follow-up stage after 3 months of inpatient treatment. In our opinion, the main reasons for achieving a good clinical result were an interdisciplinary approach to treatment, a combination of correctly performed primary surgical treatment of a wound, subsequent timely complex treatment in a specialized department, and a high regenerative potential of the child. In our opinion, the choice of the method of reconstructive intervention in patients with soft tissue and soft tissue bone defects of the scalp requires a differentiated approach, taking into account the etiology of the defect, its anatomical features and the possibility of compensating for aesthetic disorders. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. The authors declare no conflicts of interests., Тотальный отрыв кожи головы – серьезная травма в клинической практике. Часто встречается у взрослых женщин, редко – у детей. Среди детей наиболее частой причиной таких травм являются укусы животных, в том числе собак. Представлен опыт лечения ребенка двух лет, поступившего в Областную клиническую больницу № 2 г. Тюмень (Россия) с обширной укушенной скальпированной раной волосистой части головы в сочетании с черепно-мозговой травмой, травматическим шоком, множественными укушенными ранами мягких тканей головы с нарушением целостности верхнего слезного канальца. Сразу с момента транспортировки ребенка бригадой скорой медицинской помощи начата противошоковая, антибактериальная, противоотечная, симптоматическая терапия, выполнена первичная хирургическая обработка ран с восстановлением целостности верхнего слезного канальца правого глаза. Показаний к нейрохирургическому вмешательству в ребенка не было. Стандартным лечением отрыва кожи головы является, по возможности, микрохирургическая реплантация, но в связи с невозможностью проведения в данном случае микрохирургической реплантации (инфицированная рана, кожный лоскут междисциплинарным консилиумом признан нежизнеспособным) закрытие дефекта проведено отсрочено полнослойным кожным лоскутом с учетом кровоснабжения и анатомических особенностей воспринимающего ложа. В данном наблюдении в период выполнения пластики кожи головы не было послеоперационных осложнений, приживление аутодермальных трансплантатов удовлетворительное, заживление донорских ран удовлетворительное. Ребенок выписан на амбулаторный этап наблюдения через три месяца стационарного лечения. По нашему мнению, основными причинами достижения хорошего клинического результата стали междисциплинарный подход к лечению, сочетание правильно выполненной первичной хирургической обработки раны и последующего своевременного комплексного лечения в профильном отделении, а также высокий регенераторный потенциал ребенка. Выбор способа реконструктивного вмешательства у пациентов с мягкотканными и мягкотканно-костными дефектами волосистой части головы требует дифференцированного подхода с учетом этиологии дефекта, его анатомических особенностей и возможности компенсации эстетических нарушений. Исследование выполнено в соответствии с принципами Хельсинкской декларации. На проведение исследований получено информированное согласие родителей ребенка. Авторы заявляют об отсутствии конфликта интересов., Тотальний відрив шкіри голови – серйозна травма в клінічній практиці. Часто зустрічається в дорослих жінок, рідше – у дітей. Серед дітей найчастішою причиною таких травм є укуси тварин, у тому числі собак. Висвітлено досвід лікування дитини двох років, госпіталізованої до Обласної клінічної лікарні № 2 м. Тюмень (Росія) із великою укушеною скальпованою раною волосистої частини голови в поєднанні з черепно-мозковою травмою, травматичним шоком, множинними укушеними ранами м’яких тканин голови з порушенням цілісності верхнього слізного канальця. Відразу з моменту транспортування дитини бригадою швидкої медичної допомоги розпочато протишокову, антибактеріальну, протинабрякову, симптоматичну терапію, виконано первинну хірургічну обробку ран із відновленням цілісності верхнього слізного канальця правого ока. Показань до нейрохірургічного втручання в дитини не було. Стандартним лікуванням відриву шкіри голови є, за можливості, мікрохірургічна реплантація, але у зв’язку з неможливістю проведення в зазначеному випадку мікрохірургічної реплантації (інфікована рана, шкірний клапоть міждисциплінарним консиліумом визнаний нежиттєздатним) закриття дефекту проведено відстрочено повношаровим шкірним клаптем з урахуванням кровопостачання й анатомічних особливостей. У даному спостереженні в період виконання пластики шкіри голови не було післяопераційних ускладнень, приживлення аутодермального трансплантатів задовільне, загоєння донорських ран задовільне. Дитина виписана на амбулаторний етап спостереження через три місяці стаціонарного лікування. На нашу думку, основними причинами досягнення хорошого клінічного результату стали міждисциплінарний підхід до лікування, поєднання правильно виконаної первинної хірургічної обробки рани й подальшого своєчасного комплексного лікування в профільному відділенні, а також високий регенераторний потенціал дитини. Вибір способу реконструктивного втручання в пацієнтів із м’якотканинними і м’якотканинно-кістковими дефектами волосистої частини голови потребує диференційного підходу з урахуванням етіології дефекту, його анатомічних особливостей і можливості компенсації естетичних порушень. Дослідження виконано відповідно до принципів Гельсінської декларації. На проведення досліджень отримано інформовану згоду батьків дитини. Автори заявляють про відсутність конфлікту інтересів.

BACKGROUND Implantable shunt devices are critical and life saving for hydrocephalus patients. However, these devices are fraught with high complication rates including scalp dehiscence, exposure, and extrusion. In fact, high shunt valve profiles are correlated with increased complications compared to those with lower profiles. As such, we sought a new method for integrating shunt valves for those challenging patients presenting with scalp-related complications. OBJECTIVE To safely implant and integrate a hydrocephalus shunt valve device within a customized cranial implant, in an effort to limit its high-profile nature as a main contributor to shunt failure and scalp breakdown, and at the same time, improve patient satisfaction by preventing contour deformity. METHODS A 64-yr-old male presented with an extruding hydrocephalus shunt valve and chronic, open scalp wound. The shunt valve was removed and temporary shunt externalization was performed. He received 2 wk of culture-directed antibiotics. Next, a contralateral craniectomy was performed allowing a new shunt valve system to be implanted within a low-profile, customized cranial implant. All efforts were made, at the patient's request, to decrease the high-profile nature of the shunt valve contributing to his most recent complication. RESULTS First-in-human implantation was performed without complication. Postoperative shunt identification and programming was uncomplicated. The high-profile nature of the shunt valve was decreased by 87%. At 10 mo, the patient has experienced no complications and is extremely satisfied with his appearance. CONCLUSION This first-in-human experience suggests that a high-profile hydrocephalus shunt device may be safely integrated within a customized cranial implant.

Dermal regeneration template and staged split-thickness skin grafting may mitigate the need for flap coverage of postoncologic scalp defects. This technique has been studied previously in small case series. We examine the effect of risk factors, surgical technique, irradiation, and dressing modalities on reconstructive outcomes in a highly comorbid patient cohort.Retrospective review.Academic medical center.Full- and partial-thickness extirpative scalp wounds reconstructed with dermal regeneration template and staged skin grafting were reviewed over a 14-year period. Stage 1 consisted of template application following burr craniectomy in cases lacking periosteum. Stage 2 consisted of skin grafting. Negative pressure wound therapy (NPWT) was variably used to support adherence.In total, 102 patients were analyzed (average age 74, mean follow-up 18 months). Eighty-one percent were American Society of Anesthesiologists class 3 or 4. Defect size averaged 56 cmDermal template and staged skin grafting is a reliable option for postcancer scalp reconstruction in poor flap candidates. Radiotherapy is associated with adverse outcomes. Negative pressure wound therapy simplifies postoperative wound care regimens and may accelerate healing.

A 56-year-old woman was found hypothermic on her bathroom floor with a scalp wound, with laboratory results indicating long lie. She was lethargic and had difficulties finding words. CT scan revealed symmetric posterior temporal lobe hypodensities with punctiform hemorrhagic transformation (figure). Radiologic differential diagnosis included encephalitis,1 but CSF showed normal cytosis, xanthochromia, and elevated protein. Contusions are the most common intra-axial injuries, caused by sudden deceleration and impact of the brain against bone or dura mater.2 In this case, the impact occurred symmetrically against the tentorium cerebelli, presumably caused by a fall straight on the vertex while the patient was exiting the bathtub.

Limited data exist comparing staples and sutures for closing scalp wounds during Mohs micrographic surgery (MMS). We surveyed practicing Mohs surgeons who were members of the American College of Mohs Surgery (ACMS) on their scalp wound closure preferences as well as the clinical and economic variables that impact their decisions. Comparisons were made between current practice habits, preferences, and provider demographics. Sixty-eight ACMS fellowship-trained Mohs surgeons completed the survey. Overall, scalp wounds during MMS were most frequently closed using staples.

Complex cranial wounds represent complex surgical problems. In modern times, these are mostly due to accidental trauma. During the period of the American Frontier, violent scalping was a common practice. Innovative techniques were utilized to improve outcomes for this condition that still have relevance in today's practice. We provide a historical perspective with vignettes that identify survivors of violent scalping from the American Frontier as well as the surgical techniques used to treat them. The techniques identified were then modified for modern practice and applied to a complex cranial wound. A review of primary and secondary historical sources was carried out. Nine separate incidences of violent scalping were identified from this period. Successful treatment relied on exposure of the diploe leading to granulation tissue formation and eventual scalp coverage. This was accomplished as a byproduct of the violence of the scalping or as an application of the technique first described by Augustin Belloste in 1696. Application of this technique in a modern setting may allow for improved wound healing. Trepanation of the outer table to aid in healing and closure of complex cranial wounds has a long history of successful practice and can be successfully applied to modern practice.

Objective: Inexpensive methods for more rapid healing of secondary intention wounds are sought. This pilot study measured the wound healing rate for a new zinc oxide structured dressing technique. Method: In this study, we included the three patients with the largest wounds with onset during a one month period. A 3-ply gauze was cut and placed in the centre of each wound, leaving a 3-5mm rim of the wound exposed to the zinc gauze. The central gauze was soaked with 0.9% saline solution and the entire wound area was covered with 3 layers of Unna zinc oxide dressing. The central gauze size was modified to fit as the wound healed and the size changed. The wound was photographed at each visit and wound areas were obtained using best-fit ellipses. Results: The average wound closure rate is reported in the three wounds as 21.73mm2 per day. The scalp wound healed at a rate of 21.45mm2 per day.; the spider bite wound healed at a rate of 28.92mm2 per day; and the thigh wound healed at a rate of 14.81mm2 per day. Conclusion: Healing rates for the zinc gauze method exceed those previously reported for full-thickness wounds healing by secondary intention. Additional study of the new technique with more patients is needed before conclusions relevant to clinical practice can be made.

Background To know the difference between single and double-layer wound closure. Methods The study was conducted in ten patients undergoing first session of hair restoration surgery by ‘strip method’ under local anaesthesia. Informed consent was obtained from all the patients. The length and width of the strip were marked pre-operatively. Three points were marked, one in the midline ‘O’ and one on either side, ‘A’&‘B’ at 8 cm from ‘O’. After removing the strip, five deep, interrupted, absorbable sutures were applied on left half but not on the right half. Lower edge trichophytic closure was performed with no undermining of the skin edges. A single continuous non-absorbable sutures was used to close the skin. The stitches were removed on the 10th postoperative day. The patients were assessed at 9 months interval postoperatively. Results The mean age of the patients was 33.8 years. The average width of the strip removed was 15.1 mm. The average width of the scar on single-layer closure was 1.57 mm and 1.58 mm on the double-layer closure. The mobility of the scar was 7.9 mm on single-layer closure and 6.2 mm on double-layer closure. There was no statistical significance in the scar size and mobility of single-layer vs double-layer closure. The time of surgery was more in double-layer closure and the extra cost of the suture material. Conclusions There was no difference in scar quality. The extra time and money was saved in single-layer closure. The mobility of the scar was also found to be better in single-layer closure.

Tissue inelasticity and the hair-bearing nature of the scalp and forehead pose unique challenges during reconstruction. A thorough understanding of the surgical anatomy of the scalp and forehead is paramount for optimal reconstructive outcomes. Primary wound closure is usually preferred over secondary intention healing and skin grafting. Use of dermal alternatives and tissue expansion are adjunctive therapies to facilitate scalp wound closure. Local skin and soft tissue flaps are commonly used for most small to medium defects; however, microsurgical free tissue transfer can be considered for large full-thickness skin defects of the forehead and scalp.

Chronic Subdural Heamatoma (CSDH) is defined as collection of blood in the brain’s surface, subdural space between dura and arachnoid. It is one of the most common clinical entities in daily neurosurgical practice among the elders, several weeks after the head injury. CSDH doesn’t always produce symptoms but when it does, it generally requires surgical treatment. The diagnosis and treatment are well established, but the cause of recurrence, complications and related factors are not completely understood. This study evaluated the clinical features, radiological findings and surgical results in a large series of patients treated at the Neurosurgery department of Dhaka Medical College Hospital. 300 consecutive patients (250 men and 50 women) age ranging from 30-85 years, GCS 5-15, volume of blood >25cc, symptomatic with CSDH were treated by one or two burr hole craniostomies. Haematoma cavity was irrigated with normal saline and closed system subdural drainage was continued for 1-2 days from January 2012 to December 2015. The clinical outcome was measure on 1st, 3rd, 5th and 7th POD using GCS scoring and GOS after 4 and 8 weeks of operations. Most patients 94%(282) had good recovery (GOS 5,4,3), 4%(12) showed no changes (GOS 2) and 2%(6) worsened (GOS 1). Recurrence of haematoma was recognized in 5%(15) patients 1-8 weeks after the first operation. 4%(12) patients suffered post operative complications of which 1.33%(4)patients were acute subdural haematoma caused by incomplete haemostasis of the scalp wound, 1.33%(4)patients were tension pneumocephalus and remaining due to hypertension, use of anticoagulants, poor general health and medical problems. Careful haemostasis and complete replacement of subdural haematoma with normal saline to prevent influx of air into the subdural space will further improve the surgical outcome for patients with CSDH.J Dhaka Medical College, Vol. 24, No.2, October, 2015, Page 126-131

Full-thickness scalp defects pose a reconstructive problem in the setting of infection, radiation, and underlying calvarial defects. Current options include dermal matrices, skin grafts, and local fasciocutaneous flaps. Free tissue transfer is frequently required when scalp-based flaps fail or the wound is significantly large or complex. The authors present 7 patients of complex scalp defect reconstruction using the novel visor flap. The visor flap is a bipedicled advancement flap with a triangular posterior extension. The flap was designed to redistribute tension over a large surface area that prioritizes tension-free closure of the wound over a relatively small remote donor site. This method achieved complete primary healing of the recipient site in all patients. This flap design is a durable adjunct to minimize donor site morbidity and avoid microsurgical reconstruction of hostile scalp wounds.

Extensive scalp defect with exposed bone is best reconstructed with flaps. Majority of these wounds are now routinely reconstructed with free flaps in many centers. Free flaps however require lengthy operative time and may not be available to all patients, where possible less extensive options should thus be encouraged. A sixty-eight-year-old patient presented to us with a Marjolin’s ulcer on the vertex of the scalp. After wide local excision a defect of about 17 cm and 12 cm was left. The defect was successfully covered with a combination of an ipsilateral pedicle temporalis fascial flap and an axial supraorbital scalp flap with good outcome. In conclusion wide defects of the scalp can be fully covered with a combination of local flaps. The axial scalp flap and the pedicle temporalis fascial flap where applicable provide an easy and less demanding option in covering such wounds. These flaps are reliable with good blood supply and have got less donor side morbidity.

Summary: Closing a scalp wound with skin defects is challenging because the scalp skin lacks extensibility and closing it tends to result in a remarkable, widespread, hairless scar. Absorbable symmetric barbed suture device (Stratafix Symmetric; Ethicon, USA) allows wound closure using a pulling motion alone and provides a strong and secure closure for the high-tension area. We used this device to close wide scalp defects easily without tension and with minimized sequential scalp alopecia. The aim of this study was to show our experiences with using this technique. From January 2017 to March 2019, our relaxing suture technique was performed in 7 pediatric patients with scalp alopecia due to various lesions that ranged 23.0 ± 6.5 mm. After resecting the lesions, the galea was sutured using the 3-0 absorbable symmetric barbed suture via a running subcutaneous suture technique. The widespread wound edges were approximated by pulling the suture device. Wound closure was completed with galeal suturing and a superficial suture. We evaluated the width of the postoperative hairless scar at the final follow-up. In all 7 patients, we could approximate the widespread wound edges by pulling alone. Subsequently, the wounds could be closed without tension or difficulty. The mean width of the postoperative hairless scar was 3.3 ± 0.8 mm (range: 1.9–4.3 mm), and no complication was detected during the follow-up period. Our new relaxing suture technique using an absorbable barbed suture with symmetric anchors is a supportive and additional way to help close scalp defects.

It is common for patients diagnosed with severe traumatic brain injury or intracranial tumors to undergo multiple craniotomy and cranioplasty procedures. In the setting of infection, these patients can develop scalp wounds with no local options. A reverse flow anterolateral thigh (ALT) flap for coverage of a complex multifocal scalp wound in a patient with exposed cranioplasty mesh and multiple prior operations without necessitating vein grafts was presented. This might be the first reverse flow free ALT flap to be reported in head and neck reconstruction.

Patients undergoing cerebral revascularization surgery have a relatively high incidence of wound complications. We report a case of heterotopic epithelialization of the dura presenting as a non-healing scalp wound after an extracranial-intracranial (EC-IC) arterial bypass. The scalp wound was revised twice without healing. During the third revision, epithelial tissue was found growing on the dura and was removed. After the epithelial tissue was removed, the wound healed without further complications. This case illustrates the importance of thoroughly examining a non-healing wound to find the cause.

A 26-year-old male had suffered a burn injury to his scalp in childhood and ignored it. He presented with a complaint of something crawling on his head. Inspection of his scalp revealed multiple maggots on the brain surface with erosion of overlying bone and scalp. He was successfully managed by surgical debridement and regular dressing.

Electrical burns to the scalp are rare, and owing to hair coverage and the low index of suspicion, they are easy to miss. The main objective of this article is to highlight the presentation, management options and complications of the condition. A 46-year-old man with no known comorbidities had a delayed presentation with electrical burns to the scalp, legs and feet following an incident of assault. He was admitted to the Burn Unit, and supportive wound care commenced. He underwent several debridements, skin grafts of the legs and feet and left foot amputation, with improvement of the limb wounds. Despite grafting and repeated scalp wound debridement, the wound repeatedly became infected, with necrotic tissue and pus discharge. Successive tissue and wound swabs showed a varying range of bacteria that were treated with antibiotics. A computed tomography brain scan eventually showed osteomyelitis of the calvarium with sagittal sinus thrombosis. Scalp debridement and craniectomy were eventually performed in conjunction with neurosurgeons, with subsequent resolution of the wound. He was subsequently discharged with a protective helmet, with no further complications. A thorough evaluation of patients is invaluable for clinicians, and is advised in every clinical encounter. This case illustrates the challenges encountered in the management of these injuries. Thorough evaluation, repeated debridements, appropriate investigations and multidisciplinary teamwork helped to improve the outcome.

A 40-year-old man was admitted to hospital with a scalp wound but died 22 days later after unsuccessful treatment. Initial assessment of the cranial fragments removed during surgery revealed fine fracture lines on the endocranial surface, and a dark arcuate line on the ectocranial surface. To investigate the extent of the fractures a μCT scan of the fragments was taken, examined in 3D, and compared to plain radiographs. Some fractures were found to extend through the full thickness of the skull. This case presents a novel application of μCT technology to forensic radiology.

МОРФОЛОГІЧНІ ЗМІНИ У НИРКАХ НА ПЕРШУ ДОБУ В УМОВАХ ПОЛІТРАВМИ - При гістологічному дослідженні тканини нирки тварин першої дослідної групи на 1-шу добу експерименту ми спостерігали, що кірковий шар нирки був представлений клубочковим шаром. Клубочки були розширеними, повнонокровними, проте периваскулярний набряк спостерігався лише у тварин із тяжкою травмою у поєднанні з опіком та скальпованою раною. У травмованих тварин другої дослідної групи більшість вивідних канальців були розширеними, проте просвіти їх слабо візуалізувались. В петлях Ген- ле і прямих канальцях ми спостерігали виражений набряк епітелію, що різко звужувало їх просвіти. У тварин 3 дослідної групи в дистальних канальцях мали місце гідропічна білкова дистрофія, еозинофілія цитоплазми, а також слабкий зв’язок пошкодженого епітелію із базальною мембраною.МОРФОЛОГИЧЕСКИЕ ИЗМЕНЕНИЯ В ПОЧКАХ В ПЕРВЫЕ СУТКИ В УСЛОВИЯХ ПОЛИТРАВМЫ - При гистологическом исследовании ткани почки животных первой опытной группы на 1-е сутки эксперимента мы наблюдали, что корковый слой почки был представленным клубочковым слоем. Клубочки были расширенными, повнонокровнимы, однако пе- риваскулярный отек наблюдался лишь у животных с тяжелой травмой в сочетании с ожогом и скальпированной раной. В травмированных животных второй опытной группы подавляющее большинство выводных канальцев были расширены, однако просвещения их слабо визуализировались. В петлях Генле и прямых канальцах мы наблюдали выраженный отек эпителия, резко сужало их просвещения. У животных 3 исследовательской группы в дистальных канальцах имели место гидропическая белковая дистрофия, эозинофилия цитоплазмы, а также слабая связь поврежденного эпителия с базальной мембраной.CONDITION OF MORPHOLOGICAL CHANGES IN THE KIDNEYS ON THE 1ST DAY UNDER POLYTRAUMA-Histological examination of kidney tissue of first experimental group on the 1st day of the experiment, we observed that the cortical layer of the kidney glomerular layer was presented. Glomeruli were expanded, full- blooded but perivascular edema was observed only in animals with severe trauma combined with burn and wound scalp. On the other injured animals of the experimental group excretory tubules majority were expanded, but their lumen was weakly visualized. In the loop of henle and straight tubules we observed epithelial edema, which dramatically narrowed their lumen. In the experimental group 3 animals in the distal tubules occurred hidropichna dystrophy protein, cytoplasmic eosinophilia and little in the damaged epithelium with basal membraneКлючові слова: тяжка травма, опік, скальпована рана, нирки.Ключевые слова: тяжелая травма, ожог, скальпированная рана, почки.Key words: severe trauma, burns scalp wound, kidneys.

The surgical treatment of alopecia is essentially based on minigraft and micrograft techniques in which grafts are inserted into a slit or punch recipient site. To facilitate the transplantation of large numbers of these small grafts, the Calvitron automated hair transplant system has been developed. We report a case of Norwood type V alopecia who received three sessions of hair transplantation (400-500 grafts per session) over 18 months with satisfactory results. During surgery, with one technician operating the machine, one surgeon and an assistant took 3.5 to 4 hours per session to accomplish the whole procedure from harvesting the grafts to implantation and closure of the donor scalp wound. This new automated minigraft and micrograft transplant technique is significantly timesaving for large numbers of grafts per session without altering the aesthetic results. It offers a good choice for hair replacement surgery to save manpower and cost. The use of the Calvitron automated hair transplant system proved to be a practical and effective approach to hair transplantation in this case.

A 12 month prospective study was undertaken to determine the frequency of untreated life-threatening extracranial injuries in patients transferred to a major trauma centre because of head injury. Of the 43 patients transferred (15 with isolated head injury and 28 with multiple injuries), four (9%) had an untreated life-threatening extracranial injury, which caused death in two. All four patients with untreated extracranial injuries were transferred from hospitals with general surgical staff and facilities. In three of the patients (none with a major head injury), the extracranial injuries were recognized at the referring hospital, but were left untreated in the rush to transfer the patient to a neurosurgical facility. In the fourth patient, who had a severe head injury, recurrent hypotension from a ruptured spleen was mistakenly ascribed to a scalp wound. The series shows that the dangerous practice of hurriedly transferring patients to trauma centres because of actual or perceived head injuries, while leaving major extracranial injuries untreated, continues despite warnings in the literature and the efforts of the Royal Australasian College of Surgeons through the Early Management of Severe Trauma programme.

El neumoencéfalo se produce la mayoría de las veces por una solución de continuidad en el cráneo e incluso en las meninges. En ocasiones, ciertos factores pueden hacer que éste adopte las características de un neumoencéfalo a tensión provocando una clínica neurológica severa. Presentamos el caso de una paciente de 66 años portadora de una doble válvula de derivación ventrículo-peritoneal que acude a Urgencias con un cuadro de hipertensión intracraneal y que tras la exploración física y la tomografía computarizada se detecta una herida en cuero cabelludo y un neumoencéfalo a tensión. Este defecto en piel se hallaba justo en la zona del borde de una plastia craneal colocada tras la resección de un meningoma parasagital 8 años antes. Se realizó drenaje, reparación de la solución de continuidad y modificación de los factores que agravaban el cuadro del neumoencéfalo (la presencia de unas válvulas de derivación con presiones de salida muy bajas). La presencia de un neumoencéfalo a tensión debe hacernos pensar en encontrar no sólo el punto de acceso del aire al interior del cráneo sino también las causas que han favorecido que el neumoencéfalo adopte características de alta presión (sistemas de derivación o fístulas de LCR entre otros). De esta forma la orientación terapéutica adecuada tiene que ir destinada a la modificación de estos factores agravantes, además de hacia el drenaje del neumoencéfalo y cierre del defecto craneal.

El neumoencéfalo se produce la mayoría de las veces por una solución de continuidad en el cráneo e incluso en las meninges. En ocasiones, ciertos factores pueden hacer que éste adopte las características de un neumoencéfalo a tensión provocando una clínica neurológica severa. Presentamos el caso de una paciente de 66 años portadora de una doble válvula de derivación ventrículo-peritoneal que acude a Urgencias con un cuadro de hipertensión intracraneal y que tras la exploración física y la tomografía computarizada se detecta una herida en cuero cabelludo y un neumoencéfalo a tensión. Este defecto en piel se hallaba justo en la zona del borde de una plastia craneal colocada tras la resección de un meningoma parasagital 8 años antes. Se realizó drenaje, reparación de la solución de continuidad y modificación de los factores que agravaban el cuadro del neumoencéfalo (la presencia de unas válvulas de derivación con presiones de salida muy bajas). La presencia de un neumoencéfalo a tensión debe hacernos pensar en encontrar no sólo el punto de acceso del aire al interior del cráneo sino también las causas que han favorecido que el neumoencéfalo adopte características de alta presión (sistemas de derivación o fístulas de LCR entre otros). De esta forma la orientación terapéutica adecuada tiene que ir destinada a la modificación de estos factores agravantes, además de hacia el drenaje del neumoencéfalo y cierre del defecto craneal. Skull defects and even meningeal defects are responsible for the majority of pneumocephalus cases. Sometimes, several factors can produce intracranial gas under pressure (tension pneumocephalus) with severe neurological impairment. We present a case of a 66 year old woman with a double ventriculo-peritoneal shunt that was admitted to the emergency service with an intracranial hypertension syndrome. A scalp wound was found on the physical examination and a brain CT showed a tension pneumocephalus. The scalp wound was just located on the border of a cranioplasty made after surgical removal of a parasagital meningioma eight years ago. Evacuation of pneumocephalus, reparation of cranial and meningeal defects and modification of factors contributing to the tension pneumocephalus (ventricular-peritoneal shunts programmed to low pressure) were performed. When we found a patient with a tension pneumocephalus we must think not only about a skull or meningeal defect but also look for other elements that produce gas inside skull under pressure (shunts, cerebrospinal fluid leak between others). Therefore, therapeutic approach has three parts: pneumocephalus drainage, to find and repair entrance of gas and to modify factors that turn pneumocephalus in a tension pneumocephalus.

A short cut review was carried out to establish whether staples are better than sutures for scalp wound repair in children. Eight papers were found using the reported search, of which one presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this paper are tabulated. A clinical bottom line is stated.

An 82-year-old right-handed woman was brought to our emergency department following a fall during a walk in the forest. She reported a transient loss of consciousness after the fall. She had no previously known neurological or cardiac disorder and was taking no medication. Her physical examination was normal at admission except for a bleeding scalp wound. A deformity of her left temporal …

A 38-year-old healthy Caucasian man presented to the surgical team with a punctured wound on the right side of his scalp. He had been on a month's holiday to Uganda and South Africa. He recalls a painful swelling progressively increasing over 2 weeks. This was associated with sharp shooting pains and swelling on the right side of the face. He sought medical opinion while on holiday. Broad spectrum oral antibiotics were advised. The condition did not settle with the treatment so he consulted his general practitioner (GP) on return. The GP referred him to the surgical team for management of a scalp wound. On examination, a live pulsating larva was seen within a painful 1.5×2 cm puncture wound on the right side of the scalp. The larva was removed. Microbiology identified the larva as Cordylobia anthropophaga. No further treatment was advised. To our knowledge, the patient remains well to date.

My brother lay semiconscious, the concrete block from the roof beside him. Blood leaked over his face. When he came round I dragged him—in the style of a matinee war film—inside to Mum. She washed his face, put pressure on his scalp wound, then put him to bed to sleep it off. Next day he was ready for school. We lived 30 km from a medical clinic and had no car. Coughs, colds, …